Getting the right outcome for 000 patients: Revising AV s Operating Model Sue Cunningham Thursday 17 th October 2013
Agenda AV s Challenges Current Operating Model Revising Our Operating Model - what are we proposing? - what would it achieve?
Jul-07 Sep-07 Nov-07 Jan-08 Mar-08 May-08 Jul-08 Sep-08 Nov-08 Jan-09 Mar-09 May-09 Jul-09 Sep-09 Nov-09 Jan-10 Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jul-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Cases Demand Continuing growth for ambulance services over time 33,000 31,000 29,000 27,000 25,000 23,000 21,000 19,000 17,000 15,000 Cases Trend
Jul-07 Sep-07 Nov-07 Jan-08 Mar-08 May-08 Jul-08 Sep-08 Nov-08 Jan-09 Mar-09 May-09 Jul-09 Sep-09 Nov-09 Jan-10 Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jul-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Utilisation % Code 1 % <= 15 min Utilisation vs. Performance Availability of ambulances to respond 55.00 92.0 90.0 50.00 88.0 86.0 45.00 84.0 82.0 40.00 80.0 78.0 35.00 76.0 74.0 30.00 72.0
AV s challenges Rising Demand Demand growth and ageing patients AV Performance - Availability of ambulances to respond Health System - ED delays, speciality care pathways Community Expectations - Reliance on 000 for most crises Workforce - Professionalisation, post organisational reforms Resourcing Operations Plans mainly unfunded Finances - Demand diversion reduces revenue
AV s Current Operating Model 570,000 000 cases 277,000 Non-Emerg cases Emerg Call taking & Dispatch Non- Emerg Booking AV s Referral Service Emergency Services Alternative Care Services Non Emergency Services (Stretcher & Clinic Car) 531,000 cases (62.6%) 30,825 cases (3.6%) 286,000 cases (33.7%) Total Caseload: ~850,000 cases
Current Referral Service Suitable 000 Calls Alternative Care Services Secondary Triage (Referral Service) Service: Self Care Advice ASP Attendance Self Presentation Advice NEPT Transport Emergency Transport Location: Patient at home Health Service/ Medical Facility Hospital ED
Alternative Service Providers Extensive & diverse range of ASPs, incl: - Locums (out of hours) - Nurses - Mental health nurses - In reach programs (hospital medical/nursing responses) - Crisis Assessment Teams - Drug & Alcohol Counselling Services - Dental Services Patient will receive telephone contact in 1 hour, home consult & assessment, treatment within scope of practice, redirection if required All ASPs confirm attendance & outcome back to Referral
An Example Patient in a Nursing Home with Blocked Catheter Patient passed to secondary triage Private Nurse attends patient in 2 hours Patient transported to Hospital ED Subject to ED waiting, quick fix Subject to 1-2 hr wait, patient returned home via NEPT ambulance No Emerg ambulance req d No NEPT ambulance req d No ED consult req d Patient more comfortable Patient not exposed to risk of infection in ED Continuum of care maintained
Referral has proven to be safe and effective
Our most common response 000 Call Taking Triage Dispatch AV Emergency care & transport Emergency Department
Our Current Model is focused on providing emergency response is expensive (need to keep ambulances available to meet response time targets) Relies on finite resources (paramedics), with long recruitment lead times mostly takes patients to Hospital EDs: contributes to hospital congestion & further reduces ambulance availability is financially unsustainable (signficiant cost of growth) doesn t support quality patient outcomes at an efficient cost
Change is required Emerg Services 62.6% 33.7% 3.6% Non-Emergency Services: More affordable service Expandable & available market Alternative Care Services More affordable service Increasing range of services & locations Improved information available
Improving the mgmt of 000 patients Alternative Care 3.6% 4 years
Key Features 1. Aligns patient s needs with most appropriate clinical service 2. Enables better use of highly qualified (& expensive) paramedics for patients with highest medical need 3. Improves AV s operational performance our limited resources are more available 4. Aligns demand with the most cost effective service improving AV s financial viability 5. Assists with reducing hospital ED demand 6. Efficient operating model - KPI can be met more quickly and more affordably than current AV model
The Changes Required IDENTIFY PATIENT NEED Primary Triage Secondary Triage 1. IMPROVE TRIAGE CAPABILITY IDENTIFY MOST APPROPRIATE SERVICE Emerg/ Non-Emerg/Alternative Care? 2. INCREASE PATIENT PATHWAY & DESTINATION OPTIONS SELECT BEST TRANSPORT PLATFORM Emerg vs. Non-Emerg 3. IMPROVE SELECTION OF BEST TRANSPORT PLATFORM
1. Improving our Triage Capability Stage 1: Consolidate & Expand Secondary Triage Increase 000 calls being passed through to Referral, for example - extend state-wide - new call types - Accept referrals from paramedics in the field Stage 2: Integrate Primary & Secondary Triage Significantly revise & improve triage arrangements enable the appropriate care pathway to be identified at point of call (from life threatening to self care advice)
Changing Health Landscape Improvements to primary care environment occurring through Federal Government policy (National Health Reform) Health Direct Australia 24x7 telephone advice (GP Advice Line) National Health Services Directory Medicare Locals 17 in Victoria Co-ordinating local primary health care services Identifying service gaps
2. Increase patient pathways & destinations Discussions with HDA underway to access GP Advice Line & Directory of Services through secondary triage process, to ensure these services available to 000 patients Discussions occurring with Medicare Locals about the potential for AV to interface with their networks, eg. for appropriate patients to be referred to GP clinics A range of new destinations may also be investigated: - GP SuperClinics - Specialist treatment centres (eg. family violence, drug & alcohol etc)
3. Selecting most appropriate transport platform Increasing Secondary Triage will increase AV s ability to refer 000 patients to NEPT transport services There will be a limit to how many patients can be referred to NEPT transport, given current regulatory framework & guidelines Definition of non-emergency patients governed by the NEPT Act and Regulations, and embodied in the Clinical Practice Protocols (CPPs) AV will be seeking more flexibility in the CPPs to support 000 patients (of appropriate acuity) potentially being transported by NEPT resources
Another (future) example Patient has fractured neck of femur (fractured hip) Patient passed to secondary triage Patient allocated for NEPT transport Patient phones 000 NEPT crew attend, provide pain relief & transport patient to Hospital ED within 1 hour Patient transported by Emerg Ambulance to Hospital ED No Emerg Ambulance dispatch req d (& available for more critical case) Better (more timely) service for the patient
The patient s perspective. Improved service: - more flexible - more timely - more targeted Continuum of care - consistency with existing arrangements & may inform future care? New or different service experience - extended call, different platform, different fees?? New or changed perception and understanding of Ambulance Victoria eg. what services we provide
A better range of services for 000 patients 000 Call Taking Triage Dispatch Emergency Department Different transport NEPT Specialist Facility GP Super Clinic No transport required Patient at Home eg. Locum doctor or nurse
Benefits Reduces 000 callers defaulting into the emergency sector at high cost Reduces rate of growth for AV emergency activities Provides callers with better matched (targeted) care pathways reducing likelihood of repeat 000 calls and ED presentations supports speciality care pathways Improves responsiveness to most acute patients Improves AV operational and clinical performance at reduced cost of growth reapportions current volumes (where clinically appropriate) from high cost emergency sector to lower cost NEPT and alternative services
In summary.. Most appropriate Service? Emergency Transport NEPT Transport Specialist Service GP Advice Line Effective Identification of Patient Acuity Most appropriate Skill Set? ED Physician Locum (doctor or nurse) Specialist Most appropriate location? At Home Specialist Facility GP Super Clinic Hospital ED A more flexible & integrated model
Questions?